Indian Journal of Critical Care Medicine November-December 2013 Vol 17 Issue 6
Paradoxical responses have varied clinical spectrum with both pulmonary and extra pulmonary manifestations that develop at least 2 weeks after initiation of ATT and usually subside on their own.[3,4] Reversal of pregnancy induced immunosuppression may also have added to the hyper inflammatory responses in the present case there by worsening the clinical symptoms.[5] Isolation of tubercle bacilli from the cultures after excluding treatment failure, drug resistance, underlying new infection and drug hypersensitivity correlated with development of this syndrome. Interestingly, the features of IRIS manifested at an earlier stage as well following initiation of ATT. We therefore emphasize maintaining a high degree of vigilance in patients receiving mechanical ventilation and consider the development of this syndrome following ATT in worsening ARDS or newly developed ARDS. Whether paradoxical reactions are common in certain subsets of the population is still unknown. No specific disease criteria have been established as for now. The research efforts should therefore be directed to identify underlying immunopathological mechanisms triggering this condition to formulate preventive and therapeutic strategies at the earliest to protect the patient against the hyperinflammatory response without compromising antimicrobial therapy.
1
Richa Saroa1, Sanjeev Palta1, Deepak Aggarwal2, Satinder Gombar1, Puja Saxena1
Department of Anaesthesiology and Intensive Care , and 2Department of Pulmonary Medicine, Government Medical College and Hospital, Chandigarh, India
Correspondence: Dr. Richa Saroa, Department of Anaesthesiology and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030, India. E-mail: [email protected]
References 1.
2. 3. 4. 5. 396
Sharma SK, Dhooria S, Barwad P, Kadhiravan T, Ranjan S, Miglani S, et al. A study of TB-associated immune reconstitution inflammatory syndrome using the consensus case-definition. Indian J Med Res 2010;131:804-8. Memish ZA, Mah MW, Mahmood SA, Bannatyne RM, Khan MY. Immunorestitution disease involving the innate and adaptive responses. Clin Infect Dis 2000;30:882-92. Sun HY, Singh N. Immune reconstitution inflammatory syndrome in non-HIV immunocompromised patients. Curr Opin Infect Dis 2009; 22: 394-402. Lawn SD, Bekker LG, Miller RF. Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals. Lancet Infect Dis 2005; 5:361-73. Singh N, Perfect JR. Immune reconstitution syndrome and exacerbation
of infections after pregnancy. Clin Infect Dis 2007; 45: 1192-9.
Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.123466
An unusual cause of anaphylaxis during surgery Sir, A 48-year-old female was planned for left retroperitoneal laparoscopic donor nephrectomy. There was no previous history regarding any major illness or any allergic reaction to any drug or food item. On the day of surgery, intravenous Ringer’s lactate was started and all routine monitors applied. Intravenous glycopyrrolate 0.004 mg/kg, fentanyl 2 mg/kg, ranitidine 50 mg and ondansetron 8.0 mg and the antibiotic cefotaxime 1.0 gm were given intravenously. Induction of anesthesia was done with intravenous thiopentone 350 mg, and intubation was facilitated by suxamethonium bromide 100 mg. Anaesthesia was maintained with controlled ventilation using nitrous oxide, oxygen, isoflurane, and vecuronium bromide. Patient’s pulse was 80/min and BP was 130/82 mm of Hg. As patient was donor for kidney transplantation, 10-15 ml/kg/hr intravenous fluids like Ringer’s lactate solution, 500 ml gelofusine solution, and 1.0 gm/kg mannitol before clamping the renal vessels was our routine protocol. Intravenous gelofusine was started, and patient was placed on the left lateral position for surgery. Fifteen minutes after the gelofusine infusion (100 ml), atrial premature complexes were observed on ECG. Additional dose of a muscle relaxant was given, and isoflurane concentration was increased to rule out lighter plane of anesthesia. There was increased peak airway pressure on the ventilator from 25 to 50 cm of H2O. Oxygen saturation decreased from 100% to 96%. The endotracheal tube and circuits were checked for obstruction. Chest auscultation revealed bilateral extensive rhonchi. At the same time, we noticed flushing of both
Indian Journal of Critical Care Medicine November-December 2013 Vol 17 Issue 6
hands. Meanwhile, the systolic blood pressure fell to 60 mm of Hg systolic and the pulse rose to 165/minute. Suspecting an anaphylactic reaction, immediately 100% O2 was given with positive pressure ventilation. Intravenous drugs like hydrocortisone 200 mg, chlorpheniramine, mephenteramine 30 mg and 0.3 mg adrenaline (1:10000) were given. The blood pressure was maintained with vaspressors. Nebulization of ipratropium and salbutamol was administered. The surgery was postponed. As all anesthetic drugs and antibiotics were given 25 minutes before reaction, immediate hypersensitivity to Gelofusine was suspected. Gelofusine was immediately discontinued and fast intravenous ringer lactate was commenced. Within a period of 25 min, lung resistance decreased and systolic blood pressure returned to normal. Hand flushes disappeared. Patient was extubated and shifted to the ICU for observation. Four weeks after the incidence, skin reactions to the antibiotic, anesthetic drugs used and gelofusine (0.5 ml each of 1:10 dilution) were tested with a normal saline control. Gelofusine showed a reaction of 40 mm (skin wheal), confirming the diagnosis [Figure 1]. The patient was given a Medical Alert stating “allergic to Gelofusine.” Colloid plasma expanders are widely used during major surgery and play a key role in resuscitation of the severely hypovolemic patient. [1] Gelofusine is 4% modified fluid gelatin. Colloids have been recognized to cause up to 4% of all perioperative anaphylactic reactions.[2,3] Diagnosis of anaphylaxis during anesthesia may be due to different anesthetic drugs, antibiotics, latex or colloids, which can elicit heterogeneous allergic and non-allergic reactions with immediate or more delayed onset. None of the available diagnostic tests demonstrates absolute accuracy. Most anesthetic agents can cause vasodilatation, hypotension, and potential cardiopulmonary dysfunction. Several reports exist describing anaphylactic reaction to plasma expanders including Gelofusine, Haemaccel, and Dextran, [4] some of which resulted in fatalities. Dubrey et al.[5] reported severe anaphylaxis to gelofusine during a trans-thoracic echo bubble study. In our case, severe reaction occurred 15 minutes after gelofusine infusion, which was eventually confirmed by intradermal test. A high index of suspicion and prompt diagnosis should ensure successful management of anaphylaxis.
Figure 1: Skin reaction to Gelofusine in comparison to normal saline
Geeta Parikh, Veena Shah, Deepika Singh, Prachi Kadam, Nirav Kharadi
Departments of Anesthesia and Critical Care, Smt. K. M. Mehta and Smt. G. R. Doshi Institute of Kidney Diseases and Research Center, Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat, India
Correspondence: Dr. Geeta P. Parikh, 28/Yogashram Society, Near Shyamal Char Rasta, Ahmedabad - 380 015, Gujarat, India. E-mail: [email protected]
References 1. 2. 3. 4. 5.
Mishler JM 4th. Synthetic plasma volume expanders --Their pharmacology, safety and clinical efficacy. Clin Haematol 1984;13:75-92. Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reaction occurring during anaesthsia in France in 1999-2000. Anesthesiology 2003;99:536-45. Harboe T, Guttormsen AB, Irgens A, Dybendal T, Florvaag E. Anaphylaxis during anesthesia in Norway: A 6-year single-centre follow-up study. Anesthesiology 2005;102:897-903. Ghai B, Wig J, Gupta V. Intraoperative severe anaphylaxis due to gelofusine during a neurosurgical procedure. Anesth Analg 2007;104:238. Dubrey SW, Dahdal G, Grocott-Mason R. Severe anaphylaxis to Gelofusine during a transthoracic echo bubble study. Eur J Echocardiogr 2008;9:303.
Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.123467
397
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Paradoxical responses have varied clinical spectrum with both pulmonary and extra pulmonary manifestations that develop at least 2 weeks after initiation of ATT and usually subside on their own.[3,4] Reversal of pregnancy induced immunosuppression may also have added to the hyper inflammatory responses in the present case there by worsening the clinical symptoms.[5] Isolation of tubercle bacilli from the cultures after excluding treatment failure, drug resistance, underlying new infection and drug hypersensitivity correlated with development of this syndrome. Interestingly, the features of IRIS manifested at an earlier stage as well following initiation of ATT. We therefore emphasize maintaining a high degree of vigilance in patients receiving mechanical ventilation and consider the development of this syndrome following ATT in worsening ARDS or newly developed ARDS. Whether paradoxical reactions are common in certain subsets of the population is still unknown. No specific disease criteria have been established as for now. The research efforts should therefore be directed to identify underlying immunopathological mechanisms triggering this condition to formulate preventive and therapeutic strategies at the earliest to protect the patient against the hyperinflammatory response without compromising antimicrobial therapy.
1
Richa Saroa1, Sanjeev Palta1, Deepak Aggarwal2, Satinder Gombar1, Puja Saxena1
Department of Anaesthesiology and Intensive Care , and 2Department of Pulmonary Medicine, Government Medical College and Hospital, Chandigarh, India
Correspondence: Dr. Richa Saroa, Department of Anaesthesiology and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030, India. E-mail: [email protected]
References 1.
2. 3. 4. 5. 396
Sharma SK, Dhooria S, Barwad P, Kadhiravan T, Ranjan S, Miglani S, et al. A study of TB-associated immune reconstitution inflammatory syndrome using the consensus case-definition. Indian J Med Res 2010;131:804-8. Memish ZA, Mah MW, Mahmood SA, Bannatyne RM, Khan MY. Immunorestitution disease involving the innate and adaptive responses. Clin Infect Dis 2000;30:882-92. Sun HY, Singh N. Immune reconstitution inflammatory syndrome in non-HIV immunocompromised patients. Curr Opin Infect Dis 2009; 22: 394-402. Lawn SD, Bekker LG, Miller RF. Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals. Lancet Infect Dis 2005; 5:361-73. Singh N, Perfect JR. Immune reconstitution syndrome and exacerbation
of infections after pregnancy. Clin Infect Dis 2007; 45: 1192-9.
Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.123466
An unusual cause of anaphylaxis during surgery Sir, A 48-year-old female was planned for left retroperitoneal laparoscopic donor nephrectomy. There was no previous history regarding any major illness or any allergic reaction to any drug or food item. On the day of surgery, intravenous Ringer’s lactate was started and all routine monitors applied. Intravenous glycopyrrolate 0.004 mg/kg, fentanyl 2 mg/kg, ranitidine 50 mg and ondansetron 8.0 mg and the antibiotic cefotaxime 1.0 gm were given intravenously. Induction of anesthesia was done with intravenous thiopentone 350 mg, and intubation was facilitated by suxamethonium bromide 100 mg. Anaesthesia was maintained with controlled ventilation using nitrous oxide, oxygen, isoflurane, and vecuronium bromide. Patient’s pulse was 80/min and BP was 130/82 mm of Hg. As patient was donor for kidney transplantation, 10-15 ml/kg/hr intravenous fluids like Ringer’s lactate solution, 500 ml gelofusine solution, and 1.0 gm/kg mannitol before clamping the renal vessels was our routine protocol. Intravenous gelofusine was started, and patient was placed on the left lateral position for surgery. Fifteen minutes after the gelofusine infusion (100 ml), atrial premature complexes were observed on ECG. Additional dose of a muscle relaxant was given, and isoflurane concentration was increased to rule out lighter plane of anesthesia. There was increased peak airway pressure on the ventilator from 25 to 50 cm of H2O. Oxygen saturation decreased from 100% to 96%. The endotracheal tube and circuits were checked for obstruction. Chest auscultation revealed bilateral extensive rhonchi. At the same time, we noticed flushing of both
Indian Journal of Critical Care Medicine November-December 2013 Vol 17 Issue 6
hands. Meanwhile, the systolic blood pressure fell to 60 mm of Hg systolic and the pulse rose to 165/minute. Suspecting an anaphylactic reaction, immediately 100% O2 was given with positive pressure ventilation. Intravenous drugs like hydrocortisone 200 mg, chlorpheniramine, mephenteramine 30 mg and 0.3 mg adrenaline (1:10000) were given. The blood pressure was maintained with vaspressors. Nebulization of ipratropium and salbutamol was administered. The surgery was postponed. As all anesthetic drugs and antibiotics were given 25 minutes before reaction, immediate hypersensitivity to Gelofusine was suspected. Gelofusine was immediately discontinued and fast intravenous ringer lactate was commenced. Within a period of 25 min, lung resistance decreased and systolic blood pressure returned to normal. Hand flushes disappeared. Patient was extubated and shifted to the ICU for observation. Four weeks after the incidence, skin reactions to the antibiotic, anesthetic drugs used and gelofusine (0.5 ml each of 1:10 dilution) were tested with a normal saline control. Gelofusine showed a reaction of 40 mm (skin wheal), confirming the diagnosis [Figure 1]. The patient was given a Medical Alert stating “allergic to Gelofusine.” Colloid plasma expanders are widely used during major surgery and play a key role in resuscitation of the severely hypovolemic patient. [1] Gelofusine is 4% modified fluid gelatin. Colloids have been recognized to cause up to 4% of all perioperative anaphylactic reactions.[2,3] Diagnosis of anaphylaxis during anesthesia may be due to different anesthetic drugs, antibiotics, latex or colloids, which can elicit heterogeneous allergic and non-allergic reactions with immediate or more delayed onset. None of the available diagnostic tests demonstrates absolute accuracy. Most anesthetic agents can cause vasodilatation, hypotension, and potential cardiopulmonary dysfunction. Several reports exist describing anaphylactic reaction to plasma expanders including Gelofusine, Haemaccel, and Dextran, [4] some of which resulted in fatalities. Dubrey et al.[5] reported severe anaphylaxis to gelofusine during a trans-thoracic echo bubble study. In our case, severe reaction occurred 15 minutes after gelofusine infusion, which was eventually confirmed by intradermal test. A high index of suspicion and prompt diagnosis should ensure successful management of anaphylaxis.
Figure 1: Skin reaction to Gelofusine in comparison to normal saline
Geeta Parikh, Veena Shah, Deepika Singh, Prachi Kadam, Nirav Kharadi
Departments of Anesthesia and Critical Care, Smt. K. M. Mehta and Smt. G. R. Doshi Institute of Kidney Diseases and Research Center, Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat, India
Correspondence: Dr. Geeta P. Parikh, 28/Yogashram Society, Near Shyamal Char Rasta, Ahmedabad - 380 015, Gujarat, India. E-mail: [email protected]
References 1. 2. 3. 4. 5.
Mishler JM 4th. Synthetic plasma volume expanders --Their pharmacology, safety and clinical efficacy. Clin Haematol 1984;13:75-92. Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reaction occurring during anaesthsia in France in 1999-2000. Anesthesiology 2003;99:536-45. Harboe T, Guttormsen AB, Irgens A, Dybendal T, Florvaag E. Anaphylaxis during anesthesia in Norway: A 6-year single-centre follow-up study. Anesthesiology 2005;102:897-903. Ghai B, Wig J, Gupta V. Intraoperative severe anaphylaxis due to gelofusine during a neurosurgical procedure. Anesth Analg 2007;104:238. Dubrey SW, Dahdal G, Grocott-Mason R. Severe anaphylaxis to Gelofusine during a transthoracic echo bubble study. Eur J Echocardiogr 2008;9:303.
Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.123467
397
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
